Callahan C M, Stump T E, Stroupe K T, Tierney W M
Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis 46202-2859, USA.
J Am Geriatr Soc. 1998 Nov;46(11):1371-7. doi: 10.1111/j.1532-5415.1998.tb06003.x.
Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs.
To describe the distribution and content of total healthcare costs accrued over a 4-year period by a community of older adults cared for in an urban academic healthcare system and to describe high-cost patients and utilization patterns.
A cohort study.
A tax-supported public healthcare system consisting of a 450-bed hospital and seven community-based ambulatory care centers.
12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995.
Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios.
The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (+/-7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4-year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high-cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs.
Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4-year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self-care behaviors are an important target for interventions to reduce costs.
城市学术医疗中心为大量弱势老年人群提供医疗服务。这些患者往往承受着不成比例的慢性疾病、残疾和社会压力因素，这可能会增加医疗成本。
描述在城市学术医疗系统中接受治疗的老年人群体在4年期间产生的总医疗成本的分布和构成，并描述高成本患者及其利用模式。
队列研究。
一个由税收支持的公共医疗系统，包括一家拥有450张床位的医院和七个社区门诊护理中心。
1993年至1995年期间在该医疗系统中至少有两次门诊就诊和/或一次住院治疗的12581名60岁及以上的患者。
确定患者的人口统计学和临床特征、医院和门诊利用率，以及1993年至1996年产生的所有医疗成本。从医疗系统的角度使用成本收费比来估算成本。
患者的平均年龄为70岁，60%为女性，44%为黑人，83%由医疗保险和/或医疗补助覆盖。近25%的患者肥胖，15.8%有吸烟史，15.5%有营养不良迹象。每年的平均门诊就诊次数为4.3次（±7.2次），38.1%的患者曾住院一次或多次。在4年期间，24.1%的患者错过与初级保健医生的预约达5次或更多，32.7%的患者有5次或更多次非预约门诊就诊，12.5%的患者有5次或更多次急诊就诊。该老年人群体4年的总医疗成本为1.252亿美元，人均年均成本为3893美元。与住院相关的支出占医疗成本的63.6%。至少住院一次的38%患者的住院和门诊总费用占所有医疗支出的85.3%。在医院死亡的患者产生的成本并不比院外死亡的患者显著更高。在两个按人头付费系统中对5%的高成本患者进行随机逆向选择模拟，导致成本转移1110万美元。记录的吸烟史、肥胖和低血清白蛋白与成本过高显著相关。
医疗成本集中在相当一部分老年人群体中。与住院相关的成本在该老年人群体的医疗支出中占主导地位。然而，大多数老年人（83%）在4年期间住院次数为一次或更少。尽管死亡患者产生的医疗成本更高，但当死亡发生在医院时，这些成本并不更高。自我护理行为是降低成本干预措施的重要目标。
